Archive for September, 2010|Monthly archive page

I upgraded to a new android touch screen phone this week, the Motorola Backflip. What a great little device! It’s so easy to use and so much faster and lighter than my old Windows Mobile phone. The user interface was so intuitive, I barely had to open the instruction booklet.
I am having only one problem and it’s a major one…moreRead the rest of this entry »

Like this:

When a safety issue arises hospitals often convene a team to come with ideas for a safer process. Three types of teams include project teams, virtual teams, and quality circles. A project team is time limited and focused on a one-time output (Borkowski, 2011). They are usually formed to solve a particular problem and exist only until that problem is resolved (Landy & Conte, 2010). A virtual team needs technology to exist. These teams can be permanent or task focused and are defined by their ability to work across time, space and physical distance (Borkowski, 2011). Quality circles are like mini think tanks where a group of employees convenes to identify problems and generate ideas (Landy & Conte, 2010). This group submits these suggestions to management who then decide whether to act on these proposals (Landy & Conte, 2010)…more… Read the rest of this entry »

Like this:

Since staff stress is often mentioned in regard to safety issues in healthcare I thought I would post an overview of some theories of stress.

General Adaptation Syndrome
Seyle identified what is known as the stress response (Landy & Conte, 2010). This response follows the same process in humans whether the source of the stressor is physiological or psychological. This process is known as General Adaptation Syndrome (GAS) and has three stages (Landy & Conte, 2010). In the alarm reaction stage the body prepares to deal with the stressor by releasing hormones that control processes such as heart rate. In the resistance stage the body focuses on the original stressor and copes with that, however responses to any other stressors are lowered (Landy & Conte, 2010). The final stage is exhaustion and in this stage the body decreases all responses to stress (including the original source) and becomes susceptible to psychological and physiological diseases/syndromes (Landy & Conte, 2010). One of the consequences of this stage in terms of the workplace can be the development of burnout. Burnout is an extreme state of psychological Read the rest of this entry »

Like this:

In Psychology, all roads lead to Ancient Greece. The discipline of Industrial-Organizational (I-O) Psychology can trace its roots to Plato’s The Republic when he classifies citizens into guardians, auxiliaries and workers and gives selection and training advice (Katzell & Austin, 1992). In the book of Exodus, Moses sought advice on how to organize the ancient Israelis (Katzell & Austin, 1992). The study and employment of I-O Psychology principles similar to those used today however, really began in the early 1900s (Katzell & Austin, 1992).
Hugo Munsterberg, a professor at Harvard, Read the rest of this entry »

Like this:

I played tennis this morning with a friend. On the way home I thought I would stop at the supermarket to pick up some snacks for the Patriots game today. I realized I forgot my debit card (ah, the limitations of the human memory). Looking for alternate forms of payment, I found winning lottery scratch tickets in my glove compartment.
I quickly added them up (3 of them) and confirmed that … Read the rest of this entry »

Like this:

According to Kalisch, Landstrom and Hinshaw (2009) one overlooked aspect in addressing patient safety is the concept of “missed care.” Missed care is classified in terms of error as an act of omission. Missed care is a concept that nurses are very well aware of but hesitant to bring into open discussion (Kalisch, et.al, 2009). Some reasons suspected for covering up these omissions are guilt, a feeling of powerlessness to correct the situation and fear of punishment for not completing tasks. There are even reports of false documentation to hide these errors of omission because of fear of retribution and an acceptance of this being the norm (Kalisch, et al, 2009). Kalisch, et al, (2009) liken this hiding of these errors to the hiding of medication errors and near misses that was prevalent prior to the patient safety movement…. moreRead the rest of this entry »

Like this:

The link to this amazing resource is pinned at the bottom of this site. If you haven’t had a chance to check it out maybe the impressive list of journals from which they select their comentaries will entice you!Click for larger view

Take note – can you spot human factors issues that create opportunities for errors?
•What processes rely on memory?
•What tools can be used to eliminate the need to rely on memory?
•How well would the processes you observe work if the individual involved were tired? Distracted?
•What types of errors might occur? How would someone know if these error(s) had occurred?
•Are there steps that can be skipped or bypassed? Is this a good or bad design? Why?
•Would a new person be likely to make more, less or the same number of errors as an experienced person? Why?
•Are there systems in place ‐‐ or that should be in place – to minimize the opportunities for error?

If you have a chance to perform this exercise please share your observations in the comment section 🙂

Like this:

About this blog: You’ve heard of Leapfrog now there’s SafetyDog!

This blog will merge ideas from management, nursing, medicine and psychology (and many others) to offer a different view of patient safety. The author has a Masters in Industrial-Organizational Psychology, a graduate certificate in Error Science and Patient Safety and also a BSN in Nursing and has worked as an RN since 1985. All comments are welcome..you never know when one of your thoughts might save a life!

Patient Safety

IOM
Institute of Medicine..their 1999 report “To Err is human” started it all.

Leap Frog Group
The Consumer Reports for hospitals. Encouraging transparency and comparison of quality and safety.

ISMP
Institute for Safe Medication Practices. If you are looking for information on safe medication practices (and unsafe ones) they have great newsletters and other resources.

IHI
The Institute for Healthcare Improvement has an entire section on patient safety.

AHRQ
The Agency for Healthcare Research and Quality. Great site from the Department of Health and Human services. Contains research articles and safety guidelines and tools. The link is to Patient safety net

Healthcare Quarterly
Best practices and peer reviewed articles. Editor is a PhD from the University of North Carolina.